Transcript Please Click to - Tayside Centre For Organisational

The Business Case for
Quality
Gerry Marr
Chief Executive
BUDGET
- UK Economic Forecasts
1600
76.2% of
GDP
1400
1262
1200
£bn
1000
1130
36.5%
of GDP
977
800
600
527
609
Multiplied by 5 in 2 years &
represents 12.4% of GDP
200
c £17K for each
economically
active person in
the UK
c £44K for
each
economically
active person
in the UK
792
400
0
1370
35
90
175
173
140
118
97
2007- 2008- 2009- 2010- 2011- 2012- 201308
09
10
11
12
13
14
Net Borrowing
Fiscal Year
Public sector net debt - end year
Calculated
using latest
data from
National
Statistics
Budget
“Building Britain’s Future”
Overall UK Public Expenditure
• £5bn additional “value for
money” savings” in 2010/11
• Up to £9bn additional
recurring savings by 2013/14
• Real terms growth of 0.7%
between 2011/12 and 2013/14
Scottish Parliament Finance Committee Report On Strategic Budget Scrutiny
June 2009
The Centre for Public Policy for Regions (CPPR) Risk Analysis
• “By 2013-14 the (Scottish) Budget will be between roughly £2
billion and £4 billion lower in real terms than at its peak in
2009-10.
• That represents a 7 to 13 per cent real terms cut over that four
to five-year period.”
•
In the period forward to 2017-18 it expects “a return to
positive, but very low, real-terms growth of perhaps around 1
per cent.”
•
This compares with its estimate of an average of 6 per cent
per year growth in the Scottish budget over the first six or
seven years of devolution.
The Balance of Quality and Cost
Responding to what patients want and need
The Healthcare Quality Strategy for Scotland
• Person-Centred - Mutually beneficial partnerships between
patients, their families, and those delivering healthcare services
which respect individual needs and values, and which
demonstrate compassion, continuity, clear communication, and
shared decision making.
• Clinically Effective - The most appropriate treatments,
interventions, support, and services will be provided at the right
time to everyone who will benefit, and wasteful or harmful
variation will be eradicated.
• Safe - There will be no avoidable injury or harm to patients from
healthcare they receive, and an appropriate clean and safe
environment will be provided for the delivery of healthcare
services at all times.
Action Groups
Safe
Effective
Person-centred
Infrastructure
Acute SPSP
Children and
families
Ethos and
leadership
Measurement
Paediatric SPSP
Population health
Equality and
mutuality
E-health
Mental health SPSP Reshaping care
Enablement and
self-management
Communications
Primary care SPSP
Experience and
outcomes
QI Hub
HAI
Effective
practitioner
Education and
workforce
development
Governance
Physical
environment
“To improve the overall quality and efficiency
of NHSScotland while ensuring good value for
money and achieving financial targets.”
Aim, Objectives & Scope
Framework objectives:
• Quality is not compromised,
• NHSScotland will achieve
financial balance over the
SR10 period,
• NHS Boards are supported
in achieving efficiency
targets and improving
services, and
• Central co-ordination of
support, monitoring,
benefits realisation and
challenge will be available to
NHS Boards.
Three Framework themes:
•
•
•
Support – supporting our
workforce.
Enablers – identifying,
sharing, sustaining good
practice.
Cost reductions –
reducing variation, waste
and harm.
Tackling Variation –
high cost, high volume services
How is this different from
traditional cost-cutting?
• Requires process literacy and redesign
• Holds quality the same or improves it
• Needs different ways to categorize costs and
transparency
• Can unite people in a cause to control health
care costs
The paradox of plenty
What do higher spending regions -- and systems -- get?
Content / Quality of Care1,2
Technical quality worse
No more elective surgery
More hospital stays, visits, specialist use, tests
Health Outcomes1,2
Slightly higher mortality
No better function
Physician’s perceptions5
Worse communication among physicians
Greater difficulty ensuring continuity of care
Greater difficulty providing high quality care
Greater perception of scarcity
Patient-perceived quality1,3
Lower satisfaction with hospital care
Worse access to primary care
Trends over time4
Greater growth in per-capita resource use
Lower gains in survival (following AMI)
(1) Ann Intern Med: 2003; 138: 273-298
(2) Health Affairs web exclusives, October 7, 2004
(3) Health Affairs, web exclusives, Nov 16, 2005
(4) Health Affairs web exclusives, Feb 7, 2006
(5) Ann Intern Med: 2006; 144: 641-649
Improve
Safety
Thriving In
The New
Environment
Reduce “never events”
Chronic conditions self-management
Prevention and wellness (start with your staff)
Engage
Patients
Transparency for high-performing providers
Shared decision making
New models for medically complex patients
Aims:
•How much? By
When?
•“Big Dot” clinical
aims
•1-3% waste
reduction per
year, year on year
Reduce medical errors and harm
Palliative care improvement
Reduce artificial variation (LOS, use rates,
readmissions, etc.)
Improve
Efficiency
Eliminate “flow faults”
Set a goal of reducing waste by 1-3% of
operating expense budget for I year, year on year
Create a culture of getting value for money
Leadership
Adopt a proactive approach to errors and harm to
reduce malpractice claims and costs
Engage the Board
Integrating Finance and Quality
Context
Financial
Waste
Demographic
Harm
Safety & Quality
Variation
Healthcare demand is growing
Demographic change for population aged 65+ Scotland
Potential impact on emergency bed numbers 2007-2031
16000
14000
12000
NHS Tayside
+148 beds 2016
+517 beds 2031
A new Ninewells
Hospital by 2031!
84%
61%
Beds
10000
9%
8000
41%
24%
6000
4000
2000
0
Y/E Mar 2007
Projected
2011
Projected
2016
Projected
2021
Year
Projected
2026
Projected
2031
Older peoples services – why reform?
Rates of All 65+ Emergency Bed Days per 100000
Rates per 100000
population
500000
Forth Valley
400000
Greater Glasgow&Clyde
300000
Tayside
200000
Lothian
100000
Scotland
0
2004/05 2005/06 2006/07 2007/08 2008/09 2009/10
Year
Tayside estimated
65+ Bed Day cost
£63M per annum
Demographics –
84% growth by 2031
10% reduction
represents a
£6.3m annual
saving
Tayside Whole System Model Imbalance
C
Areas of Imbalance:
1.
Queues in the system
•
Referral to 1st Appointment
•
Admission queues post
Decision to admit (Ward
15)
•
Awaiting inpatient beds in
the Community
= Constraint
3.
4.
Performance Vs. Target
•
Utilisation of some
community beds
•
18 week RTT
•
Internal targets on
Turnaround
Trends
•
Increasing trend in GP
referrals up 12%
•
Urgent & Emergency
admissions up 7%
Constraints
•
Average Length of Stay in
Community Hospitals is 21
days
•
Availability of data
= Queue Before Activity
T
= Target Challenge
= Trend in Volume
= Known Issue
NHS 24
= Suspected Issue
OOH
SAS
T
acute services
Specialist
acute care
A&E
2.
Q
Walk-In
MIU
OOH, urgent & emergency
services (community)
GP
referral
acute
acute
receiving
receiving
ward
ward
(Med/Surg)
(Med/Surg)
Q
GP
T
referral
in-patient
tertiary services
rehab
Q
GP
feedback
out-patient
out-patient
Q
day patient
routine
routine
discharge
discharge
Laboratory
refer to GP
GP
direct
access
Endoscopy
Radiology
out-reach
T
complex
complex
discharge
discharge
day case
sub-contract
refer on-going
community care
Community
Pharmacists
Community
(day) Hospitals
Care in the
community
C
GP
Home Visit
GDP
Q
Optom
family health services
Q
mental health
district nursing
health visiting
specialist nursing
AHP (e.g. physio, OT)
elderly care
other
Clinic
Outpatient
Day Patient
Local
Authorities
Inpatient
Community Services – partnership model with LA
Partner & Vol
organisations
Evidence of Waste in Healthcare Systems
Six Categories of Waste (Muda)
1.
Delay: idle time spent waiting for something, such as utilization
reviews, insurer payments, test results, patient bed assignments, OR
prep, medical appointments.
2.
Re-work: performing the same task a second time, such as retesting, re-scheduling, re-filing of lost claim forms, re-writing of
patient demographic data, multiple bed moves.
3.
Overproduction: manufacturing of products or information that
is not needed, such as precautionary “defensive” medical tests,
surplus medications, excessive levels of paperwork.
Cont. 
Six Categories of Waste (Muda)
4. Movement: unnecessary transport of people, products or
information, such as requiring patients to see a primary care provider
before seeing a specialist who is clearly needed.
5. Defects: design of goods that do not meet customer needs,
such as medication errors, wrong side surgery, poor clinical
outcomes.
6. Waste of Spirit and Skill: failure to address the many
hassles in our daily work, hunting and gathering, re-calling, the same
things every day
Increase Capacity of Outpatient
Clinics?
Are there significant Outpatient Capacity losses?
25.0
20.0
Opportunity?
15.0
%
New
Return
10.0
5.0
0.0
Discharged
•
AWAITING TEST
RESULT
REFD OTHER
CLIN/HOSP
DNA-Total
Could Not Wait - FA
REFER TO OTHER
HOSP
27% of New Outpatient appointments are being wasted!
Evidence of Clinical Variation in
Healthcare Systems
Are there significant variations in hospital
expenditure by GP practice?
1,200
£ per weighted head
1,000
800
600
400
200
0
Practices
Emergency
Elective
E
AvLo dz
encheell
u eH
ArBG
r roe Hea
AbnroechveMeealth
M cruathin HHediclath CCe
ar m M eal l ent
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omel y e i th C n re
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ou e Fe tr Me u al C n e
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r A Gay Rmdical ur nttre
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Three ngfifiek Mnfoacall Cectitre
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Pr eini e
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Pa
rk
Cost per head
Are there significant variations in
prescribing practices?
Prescribing cost per head
(£)
350.00
300.00
250.00
200.00
Average £194.5
Prescribing
(£)
150.00
100.00
50.00
0.00
Practice
13091
11005
12831
11096
10106
10708
13195
11645
11931
11382
12210
11861
13571
10799
10182
11058
13621
13335
11306
10233
11171
13284
12633
11486
13231
11433
14501
11823
11414
10322
11650
10407
11166
10498
10445
10125
10286
11289
13049
13532
12281
10638
14342
12991
13706
12493
14249
10002
14569
13975
13660
10751
10361
14037
13941
10553
10036
13369
13848
13891
11363
14291
13496
13481
10017
10835
12901
13142
Cost per 1000 Patients
Are there significant variations in clinical practices in
prescribing medicines?
GIC per 1000 Patients during the period:-July 2008 to September 2008
£70,000
£60,000
£50,000
£40,000
£30,000
£20,000
£10,000
£0
Practice Reference (CHP)
Variation in Gross Ingredient Cost (GIC) per 1,000 patients across practices
11005
12633
12210
10445
12831
10182
11096
11058
11650
11306
13335
11931
11414
12281
13975
10106
10799
11861
10407
13369
11289
10708
11171
11363
13848
11433
11645
14249
14037
10125
13049
14342
13496
10361
10322
10036
10017
13941
13571
14291
10002
11166
11823
10751
10286
12991
13481
10498
13706
13195
13532
10233
11486
11382
13284
13660
10638
10835
14501
13891
13621
12901
10553
13091
12493
13231
13142
14569
DDDs per 1000 Patients
Are there significant variations in clinical
practices in prescribing medicines?
Hypnotics and Anxiolytics DDDs per 1000 Patients during the period:-July 2008 to September 2008
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
Practice Reference (CHP)
Variation by Defined Daily Dose per 1000 patients
Does spending more on medicines reduce use of
acute services?
Prescribing costs per head vs General & Acute IP/DC costs per head
Scatterplot of Gen & Acute IP/DC Total vs Prescribing _(£)
800
700
Gen & Acute IP/DC Total
Pearson
Correlation
Coefficient =
0.628
600
500
400
300
200
100
150
200
250
Prescribing _(£)
300
350
The chart shows a weak positive correlation between prescribing costs per head and
cost per head for General and Acute IP/day case spend.
This suggests that practices that tended to spend more per head on prescribing also
spent more on General & Acute IP/DC total per head in 06/07
Examples of Variation in Clinical
Practice
• Poly pharmacy
• Referral patterns into acute specialist care
• Rates of admissions in over 65 years
• Lengths of stay in over 65 years
Achieving Quality Improvement and
Cost
Reductionand Improving Services
Developing
QUALITY INITIATIVES
NEW DEVELOPMENTS
1
Costs more
2
COST REDUCTION PROGRAMMES
EFFICIENCY SAVINGS
3
4
5
Cost neutral Improves quality Quality neutral Reduces
& reduces costs
quality
Improving Quality and Reducing Costs
Our Choice
Surviving – the 5%
Thrive – the 95%
2009 - 2011
TACTICAL
STRATEGIC
PRODUCTIVITY &
EFFICIENCY
SERVICE
OPTIMISATION
CRES
DEALING WITH
THE 5%
TRANSFORMATION
SPENDING THE 95%
BETTER
2010 - 2013
TACTICAL
STRATEGIC
PRODUCTIVITY &
EFFICIENCY
SERVICE
OPTIMISATION
CRES
DEALING WITH
THE 5%
TRANSFORMATION
SPENDING THE 95%
BETTER
2010 - 2012
TACTICAL
STRATEGIC
Prevention of admission
Improved Day care
Improved service liason
and discharge
Reduced hospital stays
and bed days
Case management –
improved pathways
Intermediate care
Care home interface
Medications reviews
Housing/home care
support
Technologies
Maximise health and
social care services
Cost minimisation
Workforce efficiencies
Teleheath/telecare
DEALING WITH
THE 5%
Virtual wards
Workforce redesign
Self care and enablement
New models of care in
dementia, falls, end of life
careTHE 95%
SPENDING
Working with communities
BETTER
- coproduction
Steps to Better Healthcare
Mental
Health
Out
Patients
Theatre
Capacity /
Planned
Care
Workforce
Integrated
care
communities
Child
health
Optimisation Prescribing
of Health
and
Facilities
Medicines
across
Tayside
Scenario Planning, Financial Baselines, Benefits Tracking, Business
Cases
Workforce Modelling, Engagement & Communications with staff
Other
Labs
Maternity
Finance Support
Workforce Support
Communications with public and staff
Comms Support
Organisational Effectiveness support
OE Support
There Is No Recession In Innovation
“Fortunes are NOT made in the boom times...That is
merely the collection period. Fortunes are made in
depressions or lean times when the wise man overhauls
his mind, his methods, his resources, and gets in training
for the race to come."
George Wood Bacon